Insurance statements can be difficult to read. To help make them a little easier to understand, please see the sample bill and guide below for reference:
A.Invoice Number: You will need your specific invoice number when you pay your invoice.
B. Account Number: Identifies the specific claim submitted to Progyny for the service(s) referenced in the “Description” box.
C.Member ID: Your unique Progyny member ID number.
D.Procedure Code: Each covered test and procedure has a unique billing code. Your clinic submits claims to Progyny using this code.
E. Description: The test, treatment, or procedure connected to the procedure code.
F. Total Charges: The full cost of your treatment as billed to Progyny by your clinic.
G.Insurance Payment: The amount of your treatment covered under your Progyny benefit, as determined by your medical plan.
H.Deductible: You are responsible for paying your in-network deductible before your coinsurance starts and your coverage begins. Once you’ve met your deductible, you will only have to pay coinsurance amounts until you have reached your annual maximum out-of-pocket expense.
I. Coinsurance: The percentage of cost for a covered healthcare service you are financially
responsible for paying after you’ve met your deductible. For example, if your coinsurance is 10%, you will pay 10% of the cost of treatment and your medical plan will pay 90%. You will continue to have a cost share until your out-of-pocket maximum is met. These costs are determined by your medical plan.
J. Copayment: You may be responsible for a fixed copayment amount per appointment. The amount is determined by your medical plan.
K.Patient Balance Due: You are responsible for paying the total amount, for each line item listed on your invoice, to Progyny.
BENEFIT
1. What family building options are available through Progyny?
Progyny understands that there are many ways to grow a family. We’re here to support you—however you choose to grow your family. Under your Progyny benefit, a Smart Cycle can be broken up, mixed, or matched to cover your fertility treatment. You may pursue timed intercourse (TIC), intrauterine insemination (IUI), in vitro fertilization (IVF), or any combination that you and your specialist think is best. If surrogacy or adoption is the path you choose, your dedicated PCA can offer you support and education through this process as well.
2. What does Progyny cover?
Under a Smart Cycle, Progyny covers standard of care fertility treatment, including timed intercourse (TIC), intrauterine insemination (IUI), frozen oocyte transfer (FOT), IVF freeze-all, frozen embryo transfer (FET), and fresh IVF. Initial consultation and some stand-alone services, such as preimplantation genetic testing for aneuploidy (PGT-A), are also covered. For a more detailed review of your plan coverage options, please refer to the Explanation of Covered Treatments & Services section of your Member Guide. You can also learn about different types of treatments directly from reproductive endocrinologists in the Progyny network by visiting progyny.com/education. Please note, covered services include financial responsibility depending on your medical plan. To learn more, visit the Understanding Your Financial Responsibility section.
3. Is Progyny’s benefit inclusive of all unique paths to parenthood?
Yes, Progyny’s family building benefit was specifically designed to support all and not exclude anyone in benefit coverage, including single parents by choice and LGBTQ+ individuals and couples. Please contact your PCA to learn more about options available to you on your personal family building journey.
4. How many Smart Cycles do I have left and how should I use them?
Please contact your dedicated PCA for more information regarding your Smart Cycle balance and to discuss your options for utilizing the remainder of your benefit.
5. What’s covered in my initial consultation?
Your initial consultation includes, but is not limited to, three office visits, two ultrasounds, hormone testing, infectious disease testing, and two semen analyses. For a detailed list of coverage, please refer to the Explanation of Covered Treatments & Services section of your Member Guide.
completed diagnostic testing. To accommodate these instances, Progyny has created partial initial consult and diagnostic testing services. All providers in the Progyny network are instructed to bill for partial services in these circumstances. You may always consult with your PCA to ensure appropriate authorization and billing.
7. What’s covered under my Smart Cycle authorizations?
Each treatment authorization is valid for 60 days and covers your baseline blood test, ultrasound and monitoring appointments. Anesthesia for egg retrieval, fertilization (including ICSI), assisted hatching, preimplantation genetic testing for aneuploidy (PGT-A), cryopreservation, and embryo transfer are also covered, where applicable. To learn more about what is included in each treatment cycle, please refer to the Explanation of Covered Treatments & Services section of your Member Guide.
8. What is ICSI and is it covered?
Intracytoplasmic sperm injection (ICSI) is a procedure that uses a micropipette, or a tiny needle, to inject a single sperm into an egg to facilitate fertilization. ICSI is covered as part of your Smart Cycle.
9. What is PGT-A and is it covered?
Preimplantation genetic testing for aneuploidy (PGT-A) is a test performed on embryo biopsy tissue to test each embryo for chromosomal abnormalities in conjunction with IVF. All embryos from an IVF freeze-all and any resultant embryos remaining from the frozen oocyte transfer and Fresh IVF cycles are eligible for PGT-A testing. PGT-A is also available for embryos that were frozen prior to the commencement of your Progyny coverage. This testing is a covered service included as part of a Smart Cycle and will not affect your balance; however if performed as a standalone service 1/4 Smart Cycle will be deducted.
10.What is PGT-M and is it covered?
Preimplantation genetic testing for monogenic/single gene disease (PGT-M) is a test that is performed on an embryo biopsy at the same time as preimplantation genetic testing for aneuploidy (PGT-A). PGT-M tests for specific single gene mutations and is used if you carry a genetic mutation, such as cystic fibrosis, Tay-Sachs, or Huntington’s disease. This is a covered standalone service under your benefit and will not impact your Smart Cycle balance.
11.What is PGT-SR and is it covered?
Preimplantation genetic testing for structural rearrangements (PGT-SR) is utilized when one or both intended parents may have a balanced chromosome or structural rearrangement (inversions or translocations). PGT- SR reduces the risk of having a pregnancy or child with an unbalanced structural abnormality, which involves extra or missing genetic material and typically results in pregnancy loss. This is a covered standalone service under your benefit and will not impact your Smart Cycle balance.
12.What if my authorized IVF freeze-all or fresh IVF cycle is converted into a timed intercourse cycle (TIC)?
If your IVF freeze-all or fresh IVF treatment cycle is converted into a TIC by your provider, please contact your PCA immediately so that a new authorization can be issued. This change will impact your Smart Cycle
balance and out-of-pocket financial responsibility. If your treatment is converted into a TIC and you do not want this service counted toward your Smart Cycle balance, you have the option to pay for the service out- of-pocket. However, you will need to notify your PCA of this decision prior to the completion of your treatment. Progyny is unable to cancel authorizations once a claim from the clinic has been received.
13.What if my authorized fresh IVF cycle is converted into an IVF freeze-all cycle?
If your fresh IVF cycle is converted into an IVF freeze-all cycle, please notify your PCA of the cycle conversion as quickly as possible, as we will need to cancel or update the original authorization on file. This change will also impact your out-of-pocket financial responsibility. If you have any questions about the impact this will have, please reach out to your dedicated PCA.
14.What if my treatment is cancelled? Will it count toward my Smart Cycle balance?
In rare cases, a treatment cycle will need to be cancelled prior to completion. The following cases may arise: • Cycles cancelled prior to retrieval (or aspiration) will not be counted against your Smart Cycle
balance but will be subject to financial responsibility as determined by your medical plan. • Cycles cancelled after retrieval (or aspiration), 1/4 Smart Cycle will be deducted from your
balance.
• Cycles cancelled after fertilization due to immature or non-viable embryos prior to transfer, 1/2 Smart Cycle will be deducted from your balance
• Cycles converted to IUI or Timed Intercourse, 1/4 Smart Cycle will be deducted from your balance If you have further questions regarding cycle cancellation, contact your PCA.
15.What if my doctor requests a test that is not covered under Progyny?
If your doctor requests that you undergo a test that is not listed as a covered service under Progyny, please contact your dedicated PCA to confirm your coverage and discuss next steps regarding how to proceed. If the test is not covered under Progyny, you may be financially responsible.
For example, cholesterol, pap smear, HPV, and other tests that are not specific to fertility are not covered under Progyny but are likely covered under your regular medical insurance.
16.Are there any exclusions I should be aware of?
Standard exclusions include home ovulation prediction kits, services and supplies furnished by an out-of- network provider, and treatments considered experimental by the American Society of Reproductive
• Surgical procedures, except for egg retrievals, are not covered by your Progyny benefit. Examples of non-covered surgical procedures include hysteroscopies, laparoscopies, myomectomies, and testicular sperm extractions. Please contact your medical plan to inquire about coverage for surgical procedures.
• Pregnancy monitoring is a maternity service and therefore should be provided by your medical insurance carrier. Your Progyny benefit covers your fertility treatment until your second positive pregnancy test.
Costs will otherwise be your responsibility. Please check with your medical plan to confirm coverage.
17.What if I want to pay out-of-pocket for a service to save my Smart Cycle balance?
You have option to opt out of the use of your Smart Cycle benefit and pay out of pocket for a service in order to save your Smart Cycle balance. Please contact your PCA if you are planning to pay out of pocket for a service, as your PCA will work with your provider to arrange payment. You cannot retroactively request that authorizations be cancelled in order to self-pay for services and conserve Smart Cycles. Please be sure to check your email and alert us immediately if your clinic requests an authorization for a service for which you wish to self-pay.
18.What happens when I’ve exhausted my benefit?
When you have used your full Smart Cycle allowance, your lifetime benefits are considered exhausted. Initial consultations and other services can no longer be accessed, with the exception of any remaining storage renewals as determined by your plan. Additionally, you will continue to have ongoing access to your dedicated PCA as long as you remain an employee under an eligible plan. Progyny can continue to provide assistance by coordinating care as you move forward with your family building journey. If you would like to continue treatment, your PCA will help coordinate your appointments, speak to schedulers, labs, and clinics on your behalf, as well as continue to provide emotional support and guidance throughout your family building journey. However, once your Smart Cycle benefit has been exhausted, treatment costs will be incurred as an out of pocket cost to you.
19.Does the Progyny benefit include coverage if I want to be a donor or surrogate?
Your Progyny benefit does not cover services for you to act as a donor or gestational surrogate for another person. Donors are those donating their eggs, sperm, or embryos to another person or couple. They are not the intended parent, not an intimate partner, and not carrying the pregnancy. Gestational carriers or surrogates are also not an intimate partner and not the intended parent.
20.When do I stop using Progyny and start using my maternity coverage?
Your Progyny benefit includes coverage through your second positive pregnancy test. However, your reproductive endocrinologist may not refer you to your OB-GYN until week eight of your pregnancy. Pregnancy monitoring after that time should be billed as medical to your medical plan. However, if it is billed as fertility and denied by your medical carrier, your pregnancy monitoring will be covered by Progyny’s pregnancy gap coverage.
If pregnancy monitoring is deemed as medical, coverage will vary depending upon your health plan. Contact your medical plan to confirm coverage in advance. You may have to pay out-of-network rates or the full cost for pregnancy monitoring services if your Progyny provider is not in network with your medical plan. Contact your PCA for specific details about your medical vs. fertility benefit coverage.